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Updating Empathy Joel Yager Published online: 13 Jul 2015.

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Psychiatry, 78:134–140, 2015 Copyright Ó Washington School of Psychiatry ISSN: 0033-2747 print / 1943-281X online DOI: 10.1080/00332747.2015.1051439


Updating Empathy

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Joel Yager A fresh reading of Alberta Szalita’s (1976) article “Some Thoughts on Empathy,” honoring Frieda Fromm-Reichmann and published nearly 40 years ago, raises several interesting points: First, for practitioners in the trenches, experiences of intuitive empathy in the clinician–patient relationship are no different today than they were then; nor for Martin Buber who described I-Thou relationships in the early 20th century (Cohn, 2001; Pembroke, 2010)—nor, for that matter, for clinicians from time immemorial, undoubtedly going back to the earliest clinician/shaman/priestpatient/client/supplicant relationships. Just as Szalita described them, quoting Edith Weigert (1962), empathic experiences still consist of “[i]maginatively placing oneself in the shoes of another person in such a way as permits sympathetic understanding of his mental life” and, in so doing, “[o]ne can, however, empathize without necessarily experiencing sympathy for the other person,” in that empathy refers to understanding rather than “siding with.” Szalita’s own dictum—“It is good to be able to put yourself into someone else’s shoes, but you have to remember that you don’t wear them”— captures this well. Second, the explanatory frameworks for understanding empathic relationships available to Szalita were far less well developed than those available to us today. In the face of meager understandings of seemingly

instantaneous transmissions between empathically connected parties, some of Szalita’s contemporaries viewed empathy as mystical and mused about extrasensory telepathic phenomena to account for the mysteries of emotional contagion and the empathic connection. That was then, and this is now. In this commentary I briefly review some of the gains made in recent decades that advance our understanding of the psychological and biological mechanisms that underlie experiences of empathy, describe how current attempts of operationalizing and conceptualizing empathy are being used to study clinician–patient encounters, and describe some of the ongoing questions deserving of future research for psychotherapy education and practice. How far have we come since Szalita’s time? Several significant research thrusts have expanded our conceptual toolbox regarding empathy. First, evolutionary and cross-species understanding: To account for why big brains and complex thinking emerged, the field of evolutionary biology has generated hypotheses showing the adaptive value of being able to read another person’s mind, or having a “theory of mind.” Reduced to basics, the idea is that primates living in social groups needed bigger brains to figure out and anticipate what their peers were thinking, so that they wouldn’t be fooled or tricked into losing resources, and

Joel Yager, MD, is affiliated with the Department of Psychiatry at the University of Colorado School of Medicine in Aurora, Colorado. Address correspondence to Joel Yager, Department of Psychiatry, University of Colorado School of Medicine, 13001 East 17th Place, A011-04, Aurora, CO 80045. E-mail: [email protected] or [email protected]

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so that they might in fact pre-emptively deceive others—in other words, not only not lose but possibly also get a bigger share of resources—while still maintaining the social order that benefited everyone (Cosmides & Tooby, 1994; Duchaine, Cosmides, & Tooby, 2001). In this way, evolution favored “mind reading,” or mentalization. These hypotheses led to large numbers of experiments conclusively demonstrating the ability of several species of primates to anticipate what others in their group might do under various circumstances, and what others might be feeling—the bases of empathic experiences. Notably, these ways of looking at empathy naturally led to questions regarding the possibility that nonprimate social animals might also be empathically capable. At this point research appears to support not only conjectures that empathy is demonstrated by nonprimate social animals as diverse as rodents (Panksepp & Lahvis, 2011), elephants (Byrne et al., 2008), and cetaceans (Kuczaj, Tranel, Trone, & Hill, 2001), but also that even some nonmammals, for example, social birds such as ravens, appear to demonstrate empathy (Fraser & Bugnyar, 2010). These avenues of inquiry are under active study. Second, researchers have started to deconstruct the phenomena of empathy and intuition. Several distinguishable cognitive processes associated with empathy have delineated mechanisms that support inferences about another person’s knowledge based on nonverbal cues. Included are mirroring and mentalizing. Mirroring, referring to social inferences we make about another person’s actions or mental states, including intentions and emotions, is presumably based on processes of imitation that map our perceptions of another person’s nonverbal behavior onto our own neurological representations of experiencing these actions and associated mental states (e.g., see Gallese & Goldman, 1998). Mentalizing refers to higher-level reflective social inferences in which we create attributions of how another person feels or thinks based on his or her nonverbal


behaviors (Frith & Frith, 2012; Gallagher & Frith, 2003). Aspects of empathic processing have been further subdivided based on whether they perceive affective aspects of the other person or evaluate his or her cognitive state (Singer, 2006; Fan, Duncan, de Greck, & Northoff, 2011). With regard to intuition, researchers have proposed numerous cognitive biases, notably those underlying the “fast” knowing hunches delineated by Kahneman and Twersky as described in Kahneman’s (2011) best-selling exposition of “thinking fast and slow.” In this view cognitive and perceptual biases intrinsic to subcortical systems facilitate rapid, more or less “good enough” working models of the world that meet practical daily needs. Of course, these judgments are not always accurate. Third, associated with the psychological constructs described here, systems neuroscience has delineated several brain pathways associated with empathy, such as “mirroring” networks and “mentalizing” networks” (Singer & Lamm, 2009; Fan et al., 2011; Kuhlen, Bogler, Swerts, & Haynes, 2015). Mirror neuron systems and pathways associated with one’s own and others’ experiences, located in the premotor and inferior parietal cortex, are thought to underlie our ability to “get” another person (Iacoboni et al., 2005). The mentalizing system involves the medial prefrontal cortex, the bilateral temporoparietal junction, and the precuneus (Van Overwalle & Baetens, 2009; Baetens, Ma, Steen, & Van Overwalle, 2014). Other critical brain areas relate to experiences of affective-perceptual empathy (right dorsal anterior cingulate cortex, right and left anterior insula, and right dorsal medial thalamus, among others), and cognitive-evaluative empathy (left orbitofrontal cortex, left dorsal anterior cingulate cortex, left anterior insula, and left dorsal medial thalamus, among others) (Fan et al., 2011). In clinical conditions with diminished mind-reading capability in affected individuals, such as Asperger’s types of syndromes,

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some evidence points to deficiencies in structure and/or regulation of mirror neuron systems (Dapretto et al., 2006). In patients with temporal lobe epilepsy both cognitive and affective empathic abilities are impaired (Hennion et al., 2015). Intriguingly, in contrast to empathic deficiencies, a recent case report described a patient in whom “hyperempathy” persisting for 13 years appeared following right amygdalohippocampectomy for temporal lobe seizures (Richard-Mornas et al., 2014). Fourth, studies of psychotherapy sessions during which patients and therapists are both videotaped and concurrently studied physiologically have shown physiological concordances between participants in measures of heart rate, skin conductance, and other parameters (Marci & Orr, 2006; Marci, Ham, Moran, & Orr, 2007). Measures of “social synchrony” between mothers and infants involve activation of the same brain areas in the mothers found in studies of empathy, primarily the dorsal anterior cingulate gyrus (Atzil, Hendler, & Feldman, 2014). Fifth, studies have examined “interpersonal” or “social” intelligence,” a trait proposed as a distinct form of intelligence by Howard Gardner (1983), and, closely related, “emotional intelligence” as popularized by Daniel Goleman (1996). Evidence from behavioral genetics suggests that genetic contributions to emotional intelligence are substantial, in the order of 50% (Rushton, Fulker, Neale, Nias, & Eysenck, 1986; Davis, Luce, & Kraus, 1994; Vernon, Petrides, Bratko, & Schermer, 2008; Vernon, Villani, Schermer, & Petrides, 2008), and that emotional intelligence is not uniformly distributed in the population—in other words, some people have more and some have less; some, in fact, might be “tone deaf ” (Baughman, Schermer, Veselka, Harris, & Vernon, 2013). Is it possible that genes influencing empathic capacity distribute similar to genes for musical intelligence? Recent work has suggested that variations in genetic polymorphisms regulating oxytocin

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receptors may be associated with differences in empathic capacity (Wu, Li, & Su, 2012). Much remains to be clarified, tested, and verified in this work. But even these advances and suggestions open up important questions for research, clinical practice, and training, many of which were just as salient for Szalita as they are for today’s investigators: How can we better operationally define empathic capacity? At least eight instruments used to rate empathy in medical education settings demonstrate satisfactory reliability, internal consistency, and validity (Hemmerdinger, Stoddart, & Lilford, 2007). Recently, the acronymic mnemonic E.M.P.A. T.H.Y. introduced to outline important subcomponents for further study and training has been used as the basis of a randomized trial to study empathy training in medical house staff: E: eye contact; M: muscles of facial expression; P: posture; A: affect; T: tone of voice; H: hearing the whole patient; Y: your response (Riess & Kraft-Todd, 2014). How can we better assess empathic capacity? It’s clear that some individuals are empathically gifted, what we call “empaths” or perhaps “hyperempaths.” These abilities advantage psychiatrists, psychologists, social workers, nurses, and others who toil as psychotherapists and in other healing arts and service professions. Szalita refers to what we might think of as “receiver capacities”: listening attentively, with the ability to hear and to understand what one hears; taking in and assimilating everything in great detail, not discarding any observations, words and nonverbal communications alike; comprehensively appreciating the other person’s current experiences; grasping the other person’s intentions and motivations, including why he or she might wish to be portrayed in a certain manner, even if the individual isn’t even fully aware of those intentions and motivations in the first place. Beyond “knowing” what’s occurring in another person’s mind (cognitive evaluation), empathy requires “feeling” what the other person presumably feels (affective perception). In addition,

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accurate empaths possess considerable aptitude for self-awareness, the ability to check themselves out, having realistic and accurate appraisals of their own biases in selectively filtering or distorting information coming from others. Through these processes, good empaths might act like Fromm-Reichmann, who was “able to judge character, sense immediate need, anticipate future developments, at times with uncanny accuracy.” It is this sense of the “uncanny” that lends the aura of the paranormal to the person who is gifted with “receiving” capacities. Szalita’s descriptions also encompass empathic “responding” capacities in the service of therapeutic ends. (Here, we appreciate that some individuals who are gifted at empathically reading other people, e.g., some leaders, politicians and sociopaths, are not necessarily interested in putting their talents to therapeutic use.) In therapeutically motivated empathic responders self-awareness regarding their own reaction biases is married to the ability to self-control biases, to inhibit impulsively making wild guesses or acting in other ways that might detract from their presumably therapeutic goals. Therapeutic empaths deeply and honestly appreciate their own intentions and motivations, and acknowledge that some of their motivations might be primarily self-serving, for example, to earn a living from their work as therapists. Therapeutic empathic responses require having the right professional values—helping, not hurting, and not betraying trust or selfishly violating boundaries. Further, therapeutic empathic responding requires constantly monitoring the effects of one’s own behaviors on the patient, iteratively, to assure that communications actually convey and are received to mean what the therapist intends them to mean, and that the effects of communications actually have the intended therapeutic effects. Szalita mentions some of FrommReichmann’s additional empathic talents: She focused on the patient’s strengths and was a flexible, spontaneous actor who could easily establish intimacy and contact with patients, somehow conveying that she was


trustworthy, if not necessarily trusting, since it’s never a good idea to be gullible. To foster communications, she used dramatic but clear and simple language, another characteristic of the successful therapeutic responder. These are clearly highly nuanced behaviors. Although available rating scales provide a start, clearly much additional work is needed to fully understand and explore these issues. What cultural and social factors moderate, mediate, facilitate, or constrain one’s ability to experience empathic relationships? To what extent and in what manner? Dealing with people of other social classes, ethnicities, language groups, and so on is undoubtedly more difficult, even for the empathically gifted. What implications do these issues hold for selecting candidates for psychotherapy and other human-services training programs and helping them achieve competence and mastery? We should realistically appreciate that some individuals are probably just plain incapable of attaining the empathic capacities desirable in psychotherapists and other helping professionals. Nevertheless, for all sorts of reasons some people might wish to enter professions where empathic competence appears to constitute an essential prerequisite. How do we identify individuals who are simply empathically “tone deaf,” and who are not going to be trainable up to acceptable levels? How do we determine the least acceptable levels of empathic competence we’re willing to accept into or retain in training programs? Next, to what extent can “good enough” empathic competence be further improved by training? To what extent might we be able to help early practitioners mature from attaining excellent but sometimes erroneous “interpersonal hunches” to achieving “uncanny accuracy,” to skilled “listening with the third ear” (Reik, 1948)? We should be cautioned by observations that no demonstrations exist of additional accuracy and skill associated with experience as a therapist (Tracey, Wampold, Lichtenberg, & Goodyear, 2014). Nevertheless, with this caveat in mind

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Updating Empathy

we should still ask whether individuals with “good enough” empathic competence might become more capable empaths as a result of specific training experiences. Research on the impact of empathy training on physicians and other health professionals is very limited (Avery & Danish, 1976; Dwamena et al., 2012; Pedersen, 2010). If empathy training actually helps (Riess, Kelley, Bailey, Dunn, & Phillips, 2012; Riess & Kraft-Todd, 2014), exactly what types of training under what circumstances for what lengths of time are necessary to make a meaningful difference? Access to virtually ubiquitous videotaping and playback capabilities means that today’s training programs can rely on high definition, full fidelity observations of words, nonlexical vocal communications, and nonverbal body language transactions to test and verify clinical hypotheses regarding empathic observations and to assess trainees’ therapeutic alliances. Szalita’s suggestions that empathy training might benefit from readings and discussions of characters in novels and dramas (and of course films) complement suggestions that trainees in the helping professions might benefit from classes in “method acting” (Sarason, 1977, p. 10), which might assist them to get in touch with

deeper feelings inside themselves, to better resonate with experiences in the characters they’re asked to portray. How important is the contribution of empathy per se in determining the outcomes of psychotherapeutic treatments? Research studies focused on the role of the therapeutic alliance, a possible proxy for clinician empathy and an important “common factor” in psychotherapy, suggest that the answer is a small but respectable amount. In meta-analyses of psychotherapy outcome studies, after accounting for all other patient and therapist associated factors, approximately 5% to 15% of psychotherapy outcomes have been attributed to the quality of the therapeutic alliance per se (Feinstein, Heiman, & Yager, 2015), but much additional work remains to be done on this question. Finally, a parting question: In what ways might empathic talents contribute to a wider array of cognitive styles and capacities that all combine to create the “wise” psychotherapist (Levitt & Piazza-Bonin, 2014)? Both Szalita and Fromm-Reichmann would appear to have qualified. Wouldn’t we all love to know how to achieve that status?

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